| NPI | 1205359544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008578) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 5035) |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2022-07-15 |